Full field digital mammography: which equipment?

A wide variety of digital mammography systems are now commercially available. These include digital radiography (DR) systems such as the CSi/amorphous silicon detector (for example, GE Senographe 2000D, DS and Essential models), amorphous selenium (for example, LoRad Selenia, Siemens Novation and Inspiration models, IMS Giotto, Planmed Nuance) and a scanning system with silicon detectors (for example, Sectra Micro Dose Mammography). A variety of computerised radiography (CR) systems for mammography are also available (for example, Fuji Profect, Kodak DirectView, Konica Regius 190, Agfa CR 85-X). Recently the CR manufacturers have introduced new designs of phosphor plates. Such a wide variety of systems raises the question of how the performances of these systems compare with each other and with film-screen technology. Another factor to be considered is the radiation dose required by each system to reach an acceptable level of image quality. 
 
To help answer these questions, the National Health Service Breast Screening Programme and European Guidelines specify minimum and achievable standards for dose and image quality. The minimum standard is designed to ensure that new digital systems are at least as good as the previous film-screen systems. This lecture compares the measurements on a wide range of digital systems against the standards in the European Guidelines. The overall conclusion is that the DR systems can generally meet the achievable image quality standards for a dose lower than that used for film-screen systems. While the new designs of CR plate have brought about measurable improvements, most CR systems still require doses higher than film-screen systems to meet the minimum standards for image quality.

Current PET/CT does not have a sufficiently high accuracy for the diagnosis of primary breast cancer or for routine axillary nodal staging. Worldwide literature and our own experience show the converse to be true for metastatic breast cancer, PET/CT now being recognised as the most accurate single imaging modality to define/stage metastatic breast disease. The role of PET/CT in the patient pathway, with specific comparison with triple assessment, CT, magnetic resonance imaging and MDP bone scan is addressed. The accuracy of PET/CT for evaluation of nodal, visceral (including liver disease, brachial plexopathy and for pre/post-radio-frequency ablation evaluation) and bony disease is discussed. The important use of PET/CT for response assessment, specifically for bone disease, and its use in guiding management (re. hormone therapy, chemotherapy and radiotherapy) are highlighted. The development of more specific PET tracers, targeting the oestrogen receptor, is also discussed. Introduction Breast-sparing oncoplastic procedures (BSOP) offer a radical new alternative to mastectomy and conventional breastconserving surgery in early breast cancer treatment. Wider clearance reduces local recurrence, with a direct impact on long-term survival [1]. Loss of volume is the leading cause of breast deformity, especially for central, medial and inferior tumours [2]. BSOP require the simultaneous deployment of oncological and reconstructive skills, and the emergence of oncoplastic surgeons is increasing the availability of these procedures in clinical practice [3]. Indications BSOP are most appropriate when resecting 20% to 50% of the breast volume [4], when the likelihood of major deformity escalates [2]. New assessment tools enable direct calculation of the volume loss [2], and this approach is proving a useful alternative to total mastectomy and immediate reconstruction in patients requiring postmastectomy radiotherapy [5]. These techniques allow extremely wide local excision while minimising the sensory and structural disturbance following total mastectomy [6]. The techniques avoid the sequelae of implantbased procedures and enjoy the benefits of autologous reconstruction. Choice of technique BSOP encompass two fundamentally different approaches. Firstly, volume displacement techniques, which transpose local breast flaps into the resection defect and are most suitable for medium to large, ptotic breasts. Secondly, volume replacement techniques, which transpose autologous tissues from extramammary sites, and are most suitable for women with small to medium-sized breasts who wish to avoid volume loss. Both techniques adapt conventional methods of breast reduction or reconstruction to avoid the need for mastectomy, and a variety of volume displacement and volume replacement techniques have been described [7]. Outcomes For volume displacement, 11 retrospective studies involving 433 patients have reported local recurrence rates of 0% to 7% and cosmetic failure rates of 0% to 18% at a median followup of 21 to 54 months. For volume replacement, seven studies involving 189 patients have reported local recurrence rates of 0% to 5% and cosmetic failure rates of 0% to 9%, with a median follow-up of 24 to 53 months [7]. The clinical utility of BSOP awaits further assessment and the wider availability of oncoplastic skills [8].
Recommendations for adjuvant systemic therapies are based on estimates of life expectancy (prognostic markers) and of benefit to therapy (predictive markers). The oestrogen receptor is a classic predictive marker guiding use of anti-oestrogen therapy, and expression profiling appears to select patients more or less likely to benefit. Expression profiling is also under evaluation as a prognostic marker to identify patients who do not need cytotoxic chemotherapy (MINDACT trial). Biological therapy with trastuzumab is prescribed on the basis of a predictive test for overexpression of the target growth factor receptor protein, HER2. The ER-PR-HER2-subgroup identifies patients who may benefit selectively from platinum compounds. In radiotherapy, there is also a trend towards delivering fewer, larger fractions of breast radiotherapy to a lower total dose than the historical standard 50 Gy in 25 fractions. Partial breast radiotherapy is under test as a safe and effective alternative to whole-breast radiotherapy for women with low-risk disease, a measure that is also likely to reduce iatrogenic morbidity in long-term survivors. Finally, the identification of subgroups in which radiotherapy can be safely withheld remains a research priority, with age as the single most powerful factor predicting risk of local relapse. Amongst patients with breast cancer there is strong evidence that delays in excess of 3 months between onset of symptoms and diagnosis/treatment are associated with worse survival rates than shorter delays. The predominant risk factors for patient delays in breast cancer include lack of awareness that breast symptoms could be due to cancer and lack of awareness of personal risk.
Ideally an intervention to reduce delayed presentation of breast cancer would promote early help-seeking behaviour by patients at high risk of having cancer, but would not promote anxiety amongst people at low risk. It is important that patients should not be made unnecessarily anxious, and nor should general practitioners be overburdened with consultations with the worried well population. Based on the empirical evidence for the risk factors for patient delay and using effective behavioural change techniques, we have developed and are evaluating a psycho-educational intervention to promote early presentation of breast cancer by older women. We have focused our intervention on older women who are at greater risk of breast cancer and are also more likely to delay their presentation. The intervention is delivered by trained diagnostic radiographers at the point when the women leave the routine protection afforded by the National Health Service Breast Screening Programme and is in line with government recommended practice and complementary to the Breast Screening Programme. The ultimate aim of the intervention is to reduce the proportion of older women with breast cancer who delay their presentation, and thereby save lives. I will outline this work and other current initiatives within the United Kingdom to promote awareness and early presentation of breast cancer and how these might inform the development of policy initiatives to improve outcomes for patients within the National Health Service. Intraductal cancer or ductal carcinoma in situ (DCIS) has been considered a mammographic disease. Before the advent of mammographic screening, only about 2% to 5% of breast cancers were diagnosed in the intraductal stage. Magnetic resonance imaging (MRI) has traditionally been considered insensitive for DCIS. More recent studies, however, suggest that, with appropriate diagnostic criteria, contrast-enhanced MRI may be a very sensitive tool for diagnosing DCIS, especially high-grade DCIS. In addition, MRI has been shown to be superior to delineate the intraductal extension of invasive cancers -another reason why preoperative staging with MRI is important. The likelihood with which the mammographic diagnosis of DCIS or DCIS components fails does not correlate with mammographic breast density -in other words, a missed mammographic diagnosis of DCIS is also conceivable in women with involuted breast. The present lecture summarizes the current level of evidence, and discusses the clinical implications of these findings.  [1]. Breast 1 H MRS is performed on a clinical magnet of 1.5 T or higher in field strength. A four or more channel breast coil is also needed, just as for imaging. The most widely used technique is the single voxel technique, which is limited to scan one lesion at a time. Magnetic resonance spectroscopic imaging provides information about the spatial distribution of metabolites and is useful for studying multiple lesions [2,3]. The two main potential clinical applications of 1 H MRS include its use as an adjunct to breast MRI to improve the specificity in differentiating benign from malignant lesions and in monitoring or even predicting response to treatment in patients undergoing neoadjuvant chemotherapy. Studies have suggested that 1 H MRS may decrease the number of benign biopsies recommended by MRI [4,5]. Also, in patients undergoing neoadjuvant chemotherapy, 1 H MRS may be able to predict response as early as 24 hours after the first dose [6]. Currently, several limitations exist that make the technique premature for clinical use [7]. Preliminary data are promising, warranting further evaluation with larger, preferably multicenter, trials. The contribution of screening mammography to reducing mortality due to breast cancer in women over 40 years old has been clearly demonstrated. Nevertheless, film mammography has several technical limitations that diminish its performance in women with dense breasts. Digital mammography goes part of the way to overcoming these limitations, but its diagnostic accuracy can still be impaired by superposition of fibroglandular structures at different levels within the breast. It may be possible to improve sensitivity and specificity further by producing tomographic images of the breast through one of two new techniques, tomosynthesis or breast computed tomography. Tomosynthesis can be carried out on a modified digital mammography system in which the X-ray tube can be rotated about the breast to obtain a number of projection views over a range of different angles. The images are obtained from these projections by mathematical reconstruction. Computed tomography requires a dedicated gantry that allows a full rotation of the X-ray beam about the pendant breast as the woman lies prone on a table. Each of these imaging methods isolates structures within the breast, potentially making tumours and microcalcifications more conspicuous. Each technique has its strengths and weaknesses with respect to radiation dose and various aspects of image quality, and these will be discussed in the current presentation. In addition, trials underway to evaluate the techniques' performance will be described. Occasionally, a lesion is missed on mammography either because it lies within a region of dense surrounding breast tissue or because its X-ray absorption appears to be almost identical to that of the adjacent tissue. In breast magnetic resonance imaging, images acquired pre and post administration of an intravenous contrast agent (Gd DTPA) are subtracted to reveal pooling and washout of this agent in the presence of tumour angiogenesis, which occurs as a growing tumour recruits the development of new blood vessels. Breast magnetic resonance imaging has been shown to be much more sensitive than mammography in certain groups of young, high-risk women. It is possible to exploit this phenomenon using a much less costly and more accessible approach through contrast-enhanced digital mammography. Here, a nonionic iodine contrast agent is injected between pre and post contrast image acquisitions in which the X-ray beam is produced at a relatively high energy, above the K-edge of iodine. The images are subtracted, cancelling the soft-tissue contrast that is common to the two images and isolating the iodine signal in the region of angiogenesis. A series of post-contrast images can be obtained to track the kinetics of the uptake and washout. These images and the morphology of the lesion can reveal the presence, characteristics and extent of disease. Dual-energy approaches to improve speed or a combination of contrast imaging with tomosynthesis to provide three-dimensional images are also possible. The concept of this technique will be presented and some clinical cases will be shown. Objective To evaluate the accuracy of clinical examination and of three imaging modalities (mammography, ultrasound, and magnetic resonance imaging (MRI)) to assess the tumour response to a preoperative regimen of concurrent radiochemotherapy for large breast cancers, and to anticipate the eventual complete pathologic response.

References
Methods Sixty breast cancer women not amenable to conserving surgery at initial presentation were accrued in a phase II study. Treatment consisted of four cycles of 5-fluorouracil-vinorelbine with, starting with the second cycle of chemotherapy, radiotherapy to the breast and regional lymph nodes. Breast-conserving surgery or mastectomy was performed 4 to 6 weeks after completion of irradiation. Imaging assessment was performed before chemotherapy and preoperatively. Results Referring to pathologic data, the MRI assessment performed best. A 50% or greater decrease in the largest tumour diameter in MRI was linked to complete pathologic response with 81% sensitivity and 75% specificity. MRI-pathologic correlations helped understand the pitfalls in MRI interpretation that led to overestimating/underestimating some tumour responses.
Conclusion Compared with the other assessment modalities, MRI substantially improved the prediction of pathologic tumour response. Pitfalls or limits in MRI interpretation in this specific setting were better understood.
Introduction To evaluate the diagnostic value of combined high temporal and spatial resolution morphologic, dynamic, 1 H-spectroscopic (3D-MRSI) and diffusion-weighted magnetic resonance imaging (MRI) in patients with breast lesions at 3 T using histology as the gold standard. Materials and methods Fifteen patients were examined on a 3 T system using a four-channel breast coil. The MRI protocol included: contrast-enhanced (CE) coronal volumetric interpolated breathhold examination with high temporal resolution (isotropic 1.7 mm, time of acquisition (TA) 11.7 seconds, 17 measurements); coronal magnetization prepared rapid gradient echo at expected maximum CE (1 mm isotropic, TA 2.03 minutes); repeated coronal volumetric interpolated breathhold examination, twice-refocused singleshot echo planar imaging sequence with inversion recovery fat-saturation employing four b values (TA 4.48 minutes), 3D-MRSI (10 x 10 x 10 mm 3 ; TA 11 minutes One hundred and thirty-nine patients with core biopsy (CB)-proven unilateral primary operable invasive breast cancer underwent axillary ultrasound. Lymph nodes were identified on ultrasound in 134 patients (96%), of which 121 (87%) underwent core biopsy. The morphology of all biopsied nodes was noted. Normal lymph node was obtained in 77 CBs, 25 (32%) of which were subsequently shown to have nodal metastases. The results are presented in Table 1. The CB sensitivity for nodes with normal ultrasound morphology was 12%, for those with unilobulated cortex was 64%, for those with multilobulated cortex was 77%, for those with absent hilum was 88% and for those with multilobulated cortex and absent hilum was 100%.
In conclusion, the present study shows that an aggressive CB policy leads to an increase in sensitivity, but of relatively modest proportions, and is at the expense of a large number of normal biopsies. CB is insensitive at detecting micrometastases. CB of nodes with a normal ultrasound morphology is of little utility. S7 analyses were performed to find overall estimates of the impacts of CAD and double reading on both the cancer detection rate and the recall rate. Ten studies were found comparing single reading with CAD to single reading. Seventeen studies were found comparing double reading to single reading. Double reading generally increases the cancer detection rate, but also the recall rate. However, double reading with arbitration increases the detection rate (95% CI = 1.02 to 1.15) and decreases the recall rate (95% CI = 0.92 to 0.96). CAD does not have a significant effect on the cancer detection rate (95% CI = 0.96 to 1.13) and increases the recall rate (95% CI = 1.09 to 1.12). However, there is considerable heterogeneity in the impact on the recall rate in both sets of studies.

Medico-legal issues in breast imaging
There is better evidence for an improvement in the cancer detection rate with a human second reader than with CAD. Arbitration where two readers disagree also delivers a reduced recall rate, whereas CAD increases the recall rate. There are therefore strong grounds for preferring double reading with arbitration to single reading with CAD. with a new fully digital facility and several analogue regional subsites. Some of these latter sites have subsequently been replaced by two further digital facilities, gradually changing the proportion of digital screening mammograms from 32% to 73% of our workload over 2 years, with 53,800 women screened. This was the first digital screening site in New Zealand. We have compared the results of screening with analogue and digital technology over our first 2 years, in terms of recall rates, cancer detection rates and positive predictive value, and found no overall significant difference in any of these parameters. We have found improved detection of malignant microcalcifications with digital mammography, with a similar proportion of these malignancies that were either invasive cancer or high-grade ductal carcinoma in situ as those detected with analogue technology. However, we have found better detection of nonspecific densities with analogue imaging. There is a trend towards better cancer detection with analogue than digital technology in the 64 to 69 years age group, which does not reach statistical significance.

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Should prior film mammograms be digitised during the transition to digital mammography?
S National Health Service breast screening centres will soon make the transition to digital mammography, and how that transition is conducted may affect both performance and workflow. A trial of digitising the prior film mammograms was conducted at University Hospital (Coventry). Radiologists/advanced practitioners (n = 8) read screening cases for 1.5 hours in two conditions: either prior mammograms digitised (2905 digitiser at 75 μm; Array, USA) and presented onscreen alongside the current mammograms; or displayed in film format on a multiviewer. Measurements of eye movements showed readers look at the prior mammograms a greater number of times per case when digitised (t(7) = -2.73, P = 0.03). This could have implications for performance, as use of prior mammograms is known to improve performance. After the study, seven out of the eight readers expressed a preference for digitisation of prior mammograms. Digitisation was trialled at two different points in the workflow: before the screening session resulted in 30% wastage due to women not attending; and after the screening session caused a bottle-neck in workflow that slowed the screening process by approximately half a day (3 minutes per woman) in this implementation. The present study indicates that digitising prior mammograms is beneficial for readers, but may delay the production of results in the screening process. Digital technology has entered the practice of mammography. In the coming years, digital mammography will be gradually implemented in most European countries and will change the practice of mammography also from the radiographer's perspective. A computed radiography system is a quick simple conversion from analogue to digital; there is little change in workflow, whereas the introduction of full field digital mammography systems using direct radiography detectors implies a significant change. The X-ray film is replaced by solid-state detectors that convert X-rays into electrical signals, producing images that can be studied instantly on a computer screen. Thus, there are no cassettes, no markers, no bucky to change, no darkroom, no waiting to check films, and no viewboxes. Digital mammography provides higher resolution, which may improve detection, but it also pronounces folds and wrinkles, due to less optimal positioning. Considering the professional status of the radiographer, we encounter major differences in the various European countries. On the one hand, in some countries, screening radiographers are involved in film-reading and diagnostic procedures. On the other hand, the radiographer might just be the one pressing the button. Breast centres should employ well-trained specialized breast radiographers, as full members of the multidisciplinary team. They should be involved in the minimal invasive biopsy, ultrasound and magnetic resonance imaging techniques, as well as in upcoming new techniques, such as tomosynthesis, automated threedimensional breast ultrasound, dual-energy contrast enhanced mammography, and so forth.

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The future of breast radiography: UK perspective The current presentation reviews the radiography career structure within the mammography speciality in the United Kingdom, focusing particularly on the National Health Service Breast Screening Programme (NHSBSP). Factors influencing role design will be discussed, including national job profiles, the professional body and NHSBSP guidance, service needs and cost-effectiveness. Barriers to developing the workforce will be considered. Results from the 2008 National Breast Screening Programme workforce survey, currently underway, will be presentedconcentrating on the consultant radiographer role, and comparing actual job specifications with those indicated in the relevant guidance and with managers' views on ideal job design. It is postulated that while the radiography workforce has developed enormously during recent years, further development is needed to respond to current and future opportunities and challenges.
Within mammographic breast screening programmes in Europe, a categorisation for nonoperative histology reporting is used from B1 normal and B2 benign through to B5 malignant. Definitive diagnosis is possible for the majority of lesions on core biopsies, but there remains a small proportion in the borderline category of B3, uncertain malignant potential. These are lesions that are either benign but known to be associated with malignancy, or which are known to be heterogeneous and where sampling may have missed a more worrisome area. B3 lesions include entities such as radial scars, papillary lesions and phyllodes tumours. Often more diagnostically difficult for the pathologist are the atypical epithelial proliferations such as atypical intraductal proliferations (akin to atypical ductal hyperplasia), lobular neoplasia and columnar cell atypia/flat epithelial atypia.
Advances have been made regarding management of some of these processes; it is established that the atypical intraductal epithelial proliferations are more frequently definitively upgraded with the use of wider gauge devices (for example, 11 G, 8 G) to ductal carcinoma in situ. In such cases, diagnostic excision can be avoided and therapeutic surgery undertaken. Conversely, it has been shown that some papillary lesions may be excised by mammotomy.
There are still few robust data, however, on outcome following a B3 diagnosis of lobular neoplasia or of flat epithelial atypia. The management of these lesions when identified in the core can cause controversy and debate. Collaborative data collection of the outcome of these uncommon entities is central to resolving the question of optimal clinical management. More than 15 years ago breast radiologists recognised the limitations of fine-needle aspiration and core biopsy as methods for accurate percutaneous breast diagnosis and a variety of different devices were developed to retrieve larger needle biopsy specimens. Vacuum-assisted mammotomy (VAM) has been the most successful of these methods. While core biopsy remains the method of choice for routine needle breast biopsy, VAM is now in routine use as a proven method for minimising the sampling error of subtle and borderline breast lesions and for therapeutic excision of benign breast lesions as an alternative to surgery. VAM achieves significant 50% reduction in understaging of premalignant and malignant disease. VAM technology has been refined in recent years and there are now four different VAM devices available. All are designed for use under X-ray and ultrasound guidance. The third-generation devices are closed systems that use larger gauge probes to ensure that ample material can be rapidly acquired.
The latest devices are designed to be used with both prone table and upright X-ray equipment, and are particularly suitable for lateral approach stereotactic biopsy. Sensitivity rates for invasive and in situ carcinoma of 95% to 100% are achievable and VAM should now be considered routine for most stereotactic biopsy procedures. VAM can also be used routinely in place of surgery for the excision of benign lesions and for confirmation excision of papillary lesions and radial scars.
Comparative analyses of the current VAM devices will be presented. where the perceived risk of upgrade is low.
As the primary aim of VAEB of fibroadenomas is patient satisfaction, we sent a postal patient satisfaction survey to all 81 women who had undergone VAEB of fibroadenomas in our unit. After two postings we achieved a 59% response rate. The main findings of the survey were that 79% of patients had complete resolution of the palpable abnormality and that 96% would recommend the procedure to others and undergo a further procedure if required. Fifty-four per cent reported no pain during the procedure and only 8% reported pain as greater than 2/10 on a visual analogue scale. Postprocedure pain during the following week, however, was rated at greater than 2/10 in 55%. The commonest complication was bruising. Our unit offers VAEB to patients with B3 lesions where no atypia is present on core biopsy as an alternative to diagnostic surgical excision. We decided to audit the first 43 such cases to assess the upgrade rate and findings at follow-up imaging to see whether we needed to refine our selection criteria for VAEB. Twenty-five papillary lesions and 18 radial scars were excised under ultrasound control, the majority with an 8 G device. Following VAEB there were no upgrades of radial scars, but two lesions were missed due to difficulty in excising subtle ultrasound abnormalities and required wire localisation. Significant mammographic architectural distortion often remained following VAEB of radial scars. An 8% upgrade of papillary lesions was seen at final histology. A number of patients went on to develop further papillary lesions in the same area at follow-up. Some upgrades of papillary lesions might have been avoided by careful multidisciplinary team discussion of the core biopsies. , we implemented nurse-led and radiographer-led family history clinics. These replaced a formerly ad hoc system of general practitioner mammogram requests and referrals to the surgical breast clinic. At the clinic, women were assessed as to their level of increased risk of breast cancer by a detailed family history. They were taught breast self-examination and were put onto appropriate mammography surveillance when indicated or were reassured and discharged. The majority of referrals were from general practitioners -62% of women were found to be in the high (23%) and moderate (39%) risk categories. Thirty-eight per cent of patients were found to be at population risk (24%) or were inappropriate referrals. In conclusion: (1) nurse/radiographer-led family history clinics are effective and an efficient use of resources; (2)  Prohibitive costs of implementing direct digital mammography throughout our unit, as we would need to replace analogue machines on two mobile screening vans and at one satellite static unit, directed us towards the interim solution of computerised radiography (CR). An agreement was made between ourselves and Fuji to pilot the use of CR on a mobile screening van. We looked at the practicalities of installation of equipment, training and changes to working practices for radiographers, film-reader comparison of images and technical recall rates. The pilot has been in place for 1 year; 720 independent observations have been made by one consultant radiologist and three mammographic film-readers, comparing hardcopy CR images with previous analogue films, using the criteria set out in the National Health Service Breast Screening Programme evaluation of digital equipment document.

Breast Cancer Research
The results demonstrate that CR printed films are at least as good as analogue films, and in many cases better. The spread of relative diagnostic value was between -1 (0.4%) and +2 (14.4%) in favour of CR. This was most marked in the dense breast patterns, as shown in previous publications. Aspects of physics testing will also be discussed. Anecdotally there are many mammographers that experience musculoskeletal discomfort, although it does not feature highly in the published literature. The aim of the present project was to reduce musculoskeletal discomfort and pain associated with mammography, through examining ways of improving posture and thereby reducing muscular loading. The poster demonstrates how we evaluated our working practice with the support of ergonomic professionals, in order to reduce high-risk techniques and postures. Our evaluation led to a radical change in the way our mammographers undertake the examination. The present project has demonstrated the importance of examining our own working practice, seeking informed professional advice and being willing to change or adapt our techniques to minimize long-term health implications. Interval cancers are an important measure of screening quality and, although they are an expected and inevitable part of any cancer screening process, their numbers should be kept as low as possible.

Comparison between the NVQ Level 3 in Diagnostic and
Interval breast cancer cases may be identified from a number of sources, including symptomatic clinics, pathology laboratories and cancer registries. The South West Quality Assurance Reference Centre (QARC) has developed a database to assist in the collection and validation of interval cancer data. The database has been developed collaboratively with the South West Cancer Registry, which sits within the South West Public Health Organisation (SWPHO). Service-level agreements are in place between the QARC and the nine Trusts hosting the Breast Screening Units and with the SWPHO. The present poster details the information flows between the breast screening units in the South West, QARC and the SWPHO by comparing and contrasting viable data items. The system not only identifies potential interval cancers but will also aid validation and verification of cancer data held by the SWPHO. Validated data will be fed back to the screening units.

S14
Objective To review the clinical and imaging presentation of MB and to differentiate these from PBM. Method We retrospectively identified over a 15-month period six pathologically proven cases of MB from an extramammary malignancy. The clinical, ultrasound and mammographic presentations are tabulated. These are compared with the features of PBM.
Results Primary tumours included one melanoma, two lung cancers, one lymphoma, one gynaecological malignancy and one unknown primary. The MB was the presenting feature in four out of six cases. Five patients had both mammogram and ultrasound examinations, and one of these had breast MRI in addition; one patient had ultrasound only. Imaging features were similar to those discussed in the literature and include well-defined nodules, associated axillary lymphadenopathy and an absence of distortion or microcalcifications. Conclusion Although radiological appearances may be helpful, MB must be differentiated from PBM by appropriate histopathologic examination, in order to preclude unnecessary mastectomy and to guide further management. The purpose of the present poster is to highlight the efficiency and cost-effectiveness of a mammographer-led sentinel node injection session within a specialist breast care centre. The axillary lymph node status provides the most important staging information and offers improved regional control. Sentinel lymph node biopsy has been reported as providing a safe and sensitive method of predicting axillary metastases and can help prevent unnecessary axillary surgery in a number of breast cancer patients [1]. Sentinel node injections have developed into a significant aspect of the mammographer's role expansion and have become fundamental in a specialised breast care centre. Utilisation of mammographer's skills in an extended role has increased motivation and job satisfaction and has provided career enhancement. Mammographer-led sentinel node injection sessions have reduced the inpatient stay, improved the patient's journey and reduced the dose of radioisotope given to the patient. Three patients underwent surgical excision, 10 underwent Mammotome biopsy and two patients had no subsequent procedure. All three patients undergoing surgery showed benign intraductal papillomata. Of the 10 patients undergoing Mammotome, eight were confirmed as benign. None subsequently developed malignancy. One Mammotome patient contained ductal carcinoma in situ (DCIS); another, an atypical epithelial proliferation resulting in surgery and a subsequent diagnosis of DCIS. Both cases were distinctive in presenting with segmental calcification, and in both DCIS had arisen in the context of multiple papillomata. Large-volume Mammotome biopsy may reduce the need for surgery in selected screen-detected papillary lesions.

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Significance of new benign densities seen on screening mammograms of women older than 60 years of age Breast cancer risk is strongly related to age, with 80% of cases occurring in women over 50 years old. Small, benign-looking lesions in perimenopausal women have a very low risk of malignancy and are not recalled. We undertook an audit to assess the significance of a single, new, apparently benign (R2) lesion seen on both views on screening mammograms of women aged 60 years and above. Any new density with suspicious imaging was recalled without being entered into the audit. A total of 70 women were included. Fifty-seven patients had no significant findings or cysts on ultrasound, with a normal postaspiration mammogram. Three patients had cyst aspirate sent for cytology, and one of these went on to have a core biopsy for a C3 result. Ten patients had a solid lesion on ultrasound warranting a core biopsy, two of which had a B5 lesion. Although the majority of patients had a benign result, a total of three out of 70 patients had an abnormal cytology/histology. We recommend that new benign densities seen on two views in women aged over 60 years old are fully assessed and biopsied to determine their nature.
Introduction Screening women in the Southern Region of Ireland commenced in December 2007. Prior to this, screening was only available in the eastern regions and the two units in this region had a mix of analogue and digital equipment. Background Although the BreastCheck Southern Unit is working with digital systems, our clinicians have come from an analogue background. Practice shows that, despite manufacturers' claims on the reduced need for certain imaging at assessment, this is not happening in reality. Historically, women recalled to assessment had a number of further views, ultrasound and, in some instances, a biopsy performed. The average time spent in the clinic for each woman was 2 hours. As this unit is digital and has only commenced its service, an audit was commissioned.
Methods The audit will include data for a 4-month period from January 2008, involving all women recalled to assessment. The following will be evaluated: compression used at initial screen and whether low levels of compression increase the recall rate; further imaging and whether these images add any new information to aid diagnosis, especially with the advances in digital imaging; and streamlining the clinics to provide a more efficient service for our clients.

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Derby results and practical experience of breast imaging in women following supradiaphragmatic irradiation for Hodgkin's disease In the group offered imaging surveillance, all 33 women took up the invitation. When magnetic resonance imaging (MRI) is indicated, it is done first; then the woman attends for mammography, MRI results and any focused ultrasound needed the following day.
See Table 1 for results. Five of the six MRI recalls were from a first screen, and the other from a second screen. One ductal carcinoma in situ was diagnosed in a lady with breast implants. From the 56 eligible women, there were four with breast cancer: one woman diagnosed as above, two women from the National Health Service Breast Screening Programme and one woman symptomatically in 2007. The radiology and pathology of these cases will be presented. We commence family history screening with MRI soon and plan to apply this method, which works very well and within tight time limits. Within the National Standards for Breast Screening is the objective to ensure that women are recalled for screening at appropriate intervals. The Manchester Breast Screening Unit has utilised the ability to specify batches from the health authorities in a specific order, to maximise the call and recall system for women eligible for primary screening. The minimum standard for the criterion of the percentage of eligible women whose first offered appointment is within 36 months of their previous screen is ≥90%. Using the computer program has maximised the appointment scheduling, but in addition has derived benefits to the Commissioning Primary Care Trusts. The appointment timescales, offering women screening on mobile vans, has enabled the Primary Care Trusts the opportunity to promote breast screening effectively to the eligible women who have failed to attend their first appointment. In low-uptake areas, this has facilitated the efforts to increase uptake to the national standard of 70%. Radial scars present a difficult problem within breast screening. A proportion contains a spectrum of pathological change, including invasive cancer [1]. For this reason, surgical excision has been recommended [1]. With increasing use of vacuum-assisted biopsy, recommendations are now in place to allow leaving these lesions without excision where no atypia is identified [2].

Maximising round length in a large
Breast Cancer Research July 2008 Vol 10 Suppl 3 Symposium Mammographicum 2008

S17
We present our series of 100 B3 radial scars consecutively diagnosed by 14-gauge core biopsy between 2004 and 2007. This includes 13 malignancies subsequently identified on surgical excision. Five were invasive (size, 2 mm to 11 mm), and eight were ductal carcinoma in situ (size, 3 mm to 22 mm). In three cases of invasive cancer <10 mm, no concomitant atypia was identified. In these cases, had vacuum-assisted biopsy not included the small invasive area, surgical excision would not have been recommended under current guidelines. Hence, the cancers would have remained undetected. This information will continue to inform the debate surrounding surgical excision versus vacuum-assisted biopsy without excision in the management of radial scars. Background The goal of this research collaboration was to establish whether mammography units within New South Wales, Australia (NSW) and the Republic of Ireland (ROI) have dedicated mammography-specific infection control protocols and the extent of cleaning/disinfection of these units. Possible vectors for increased bio-load on hospitals/outpatient facilities specifically due to these mammography units were also examined. During mammography, patients' friable skin is in close contact with equipment/hands; possibility of infection spread is highest where immunity has been lowered by the disease process. Method A questionnaire underpinned by worldwide infection control guidelines was formulated and circulated to radiographers in symptomatic/asymptomatic mammography units within the ROI and NSW. Results Whilst mammography-specific infection control protocols were available in fewer ROI units (25%) than NSW units (32%), NSW mammographers (43%) had less access to documented protocols (versus 94% for ROI units). Significant variation in cleaning methods, consistency and procedures was observed in both regions. Infection control is not routinely included in the quality assurance process of all units. Conclusion Many aspects of infection control procedures are less than satisfactory. These procedures should be regulated with specific mammography infection control protocols within the quality assurance process to prevent patient cross-infection, with a consequent lowering of biological burden on hospital/outpatient facilities.

Introduction
To assess the diagnostic accuracy of 1 H-spectroscopic (3D-MRSI) and diffusion-weighted magnetic resonance imaging (DWI) in comparison with high-temporal and spatial resolution dynamic MRI in patients with breast lesions at 3 T.  The Personal Performance in Mammographic Screening (PERFORMS) scheme originated in 1991 and functions as a free educational tool whereby film-readers routinely evaluate and receive immediate and confidential feedback on 120 cases, biyearly. In addition, most individuals complete a short questionnaire describing real-life factors such as years of reading experience and most typical screening practice (for example, reading duration, frequency, and case volume). From these data we identified those individuals who performed best (as a measure of excellence in filmreading) and those who performed less well on PERFORMS with a view to establishing a general film-reader profile. Previous research has shown that individuals who read a lower volume of cases (for example, new film-readers) may perform less well for sensitivity measures. We also looked at occupational differences in these profiles to determine whether radiologists and advanced practitioners were significantly represented in either performance group. We investigated low/high group profiles by analysing over 400 film-readers' questionnaire/performance data for a recent PERFORMS scheme. This analysis concentrated on possible within-group similarities in style and manner of film-reading according to self-report. We elucidate what characteristics and practices, from self-report, are the most common for breast-screening film-readers within a high/low performance group, with a view to possible training recommendations.  (2008) has recently been launched and is a practical guide for quality assurance reference centres, cancer registries and breast screening units to record and report interval cancers, with the aim of standardising practice across the United Kingdom. Coventry has always been at the forefront of this important work and, as part of the skill mix, the role of collecting and reporting data has been taken on by radiography film-readers. Coventry is the base for four different primary care trusts and the film-readers have links with multidisciplinary team meetings, breast care nurses, pathology and X-ray departments from all these areas, and are also involved with symptomatic mammography and local and regional interval cancer audits. The present poster demonstrates the pathway taken to collect and record information for audit and to forward it to the quality assurance reference centre for regional and national review. Objective To report the experiences of research radiographers in delivering the 10-minute intervention to women in breast screening clinics.

Materials and methods
Methods Reflective diaries and supervision records were used to collate the experiences of radiographers delivering the intervention as part of a research trial and to discuss emerging issues and challenges for widening the role of diagnostic radiographers across the National Health Service.

Results
The main challenges included learning and rehearsing a structured interview, delivering complex health messages within time constraints using behavioural change techniques, and dealing with unexpected events, including emotional distress, during interviews. Benefits included enhanced interaction with women attending screening and extending the usual role of the radiographer.
Conclusion It was beneficial yet demanding for radiographers to extend their role in this way. Not all radiographers may be motivated or suitable to undertake this work. Training and ongoing supervision are essential to support radiographers who deliver the intervention. Patients were subdivided into one of four groups according to the size of the calcification cluster and the pathology was reviewed to investigate the likelihood of diagnosing malignancy, either in situ or invasive, with differing extents of radiological abnormality. Further mammographic views were performed in all cases and stereotactic core biopsy in 252 cases (89%). Thirty-one patients were felt to either not be suitable for or not to need biopsy after further mammography and were subsequently placed on early clinic review or routine recall. Where the biopsy failed to obtain calcification, the options of mammotome or early review were considered at the multidisciplinary team meeting. A summary of the findings is presented in Table 1. Demonstrations of a prototype were used to elicit requirements for a training system for screening mammography. The prototype allowed mentors to select cases from a distributed image database to meet the specific requirements of trainees. Trainees received automated feedback in response to attempts at interpretation. The prototype was demonstrated to radiologists and radiographers. Comments were recorded and used to elaborate requirements for a more sophisticated version. The main classes of response were as follows: automated marking and feedback -where the trainee's interpretation did not match the experts' opinion exactly, the prototype acted is if the trainee required correction, which was not always appropriate; integrating with existing training practices -discussion between trainees and mentors is important, and suggestions for supporting such communication included providing comment facilities and the ability to bookmark cases for further discussion; and searching and browsing cases to build training sets -the provision for constructing training sets appropriate for different teaching goals is highly valued. We are following an iterative process where requirements are gathered, and prototypes are constructed, evaluated by users and then refined until users are satisfied that their requirements have been met. A new version of the tool has been developed. The introduction of digital mammography opens up new opportunities to provide a wide range of training to individuals without the restriction of the mammographic multiviewer. Whilst high-resolution monitors in an appropriate viewing environment are de rigour for actual reporting of screening cases, the advantage of the digital image over film is in the flexibility of training opportunity afforded (for example, web-based training, or tailored training on personal digital assistants). A previous study indicated the possible potential for reporting mammographic cases utilising handheld devices (providing suitable human-computer interaction techniques are employed). The UK self-assessment scheme Personal Performance in Mammographic Screening (PERFORMS) has also identified where tailored training may be beneficial. Initially, groups of mammographers were questioned in semistructured interviews in order to help establish film-readers' training preferences.
Content analysis revealed several main categories of training issues, including requirements of individualised tailored training, the location and timing of training opportunities, the ease of user interaction and film-readers' perspectives on the possible clinical applicability of mobile devices. Subsequently, several breast screening units completed a questionnaire concerning current and anticipated training requirements. It is concluded that digital breast imaging facilities tailored training for an individual that can be achieved using mobile devices, and this is currently under development. Mammographic screening for women at increased risk due to a family history commenced in 2001 in Wales. Forty-one cancers have been found, and 31 were screen detected. One-half were in the high-risk category.

A review of breast cancers found in the Welsh
Of the high-risk cancers, 47% were grade 3 and 41% were nodepositive, despite annual screening. Ductal carcinoma in situ was frequently found, and 75% of this was of high nuclear grade. In the moderate-risk group there was an even spread of cancer grade, fewer cases of ductal carcinoma in situ and no node-positive tumours.
The most common mammographic findings were calcification and glandular asymmetry.

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Common uses of immunohistochemistry in interpreting lesions of the breast: a pictorial review The present pictorial review includes a brief explanation of the basic principles involved in immunohistochemistry and an overview of its use as a problem-solving and prognostic tool in the context of breast disease. Myoepithelial markers cytokeratins 5/6, p63 and smooth muscle actin are helpful in distinguishing lesions that mimic invasion, namely radial scar and sclerosing adenosis from invasive lesions. These markers can also be used in differentiating intraductal papilloma from papillary carcinoma, and their patterns of expression can help distinguish ductal carcinoma in situ from atypical ductal hyperplasia. Epithelial markers such as AE1/AE3 and cytokeratin 7 may identify subtle foci of stromal invasion and micrometastasis in lymph nodes. Each of the above scenarios is illustrated with radiological and pathological images, and shows the role of immunohistochemistry in attempting to resolve these diagnostic dilemmas.
The role of this technique in the typing of certain breast tumours is discussed and illustrated using E-cadherin in distinguishing ductal from lobular carcinoma. Finally, the prognostic role of immunohistochemistry in oestrogen receptor, progesterone receptor and human epidermal growth factor receptor 2 analysis for primary breast carcinomas is illustrated.